time allocation in primary care office visits

Tai-Seale, McGuire, and Zhang,

HSR 2007

AcknowledgementNIMH (MH01935) , NIA (AG15737) for fundingComments from Margarita Alegria, John Z. Ayanian,

Howard Beckman, Richard Frankel, Richard Kravitz, Rachel Moser, Joseph Newhouse, Richard Street, Jr. and Suojin Wang

Editors Hal Luft, Jose Escarce, and two anonymous reviewers

Research assistants

AcademyHealth 2008 2

MotivationMedical office visit is the foundation of

medical care It is one of the most important professional

activities of primary care physicians Evidence continues to show a gap between

science and clinical practiceRacial minority patients fare even worse


Realities of PracticeTime is scarce in primary care, 2,000 –

3,000 patients/physician, 15 min/visitCompeting demands aboundUnder pressure to be “productive” and have

short visitsQuality of care often falls short (McGlynn

2003)Proliferation of practice guidelinesAvailability of guidelines does not translate

into guideline concordant practice nor positive patient health outcome


Some Physicians’ Analogies“Hamster” wheel (NYT)Doc on roller skatesPush the current patient

as quickly as possible so the next patient can be seen (Callahan 2006)


Selected Literature Beckman and Frankel (1984)

Patients spoke for 18 seconds before interruption

Marvel et al (1999) Patients spoke for 23 seconds before interruption


Our Main GoalCharacterize patient-physician relationship in a new way

Study how physicians and patients allocate the scarce resource of visit time to deal with complex issues in office visits


Methodological RequirementsExaminations of complex reality require

suitable empirical research methodsHerbert Simon and Amos Tversky

advocated collecting data from observations of actual behavior

Lisa Cooper stressed the need for triangulating surveys with direct observation of the actual encounter


Direct observation


To Err is HumanThis is a very critical

way of studying physician behavior.

Humility and self-reflection are needed on the part of the researcher.


Research QuestionsWhat was the length of primary care office

visitsWhat topics were discussed How many topics were discussed in each visitHow much time was devoted to each topicWhat factors influenced the length of

Discussion on topics Visits


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DataVideotapes

392 patient visits35 primary care physicians 3 types of practice settings1999-2000

Patient surveyPhysician survey

TimeEnd of VisitBeginning

Patient Talks

Physician TalksAnxiety aboutheart failure

Elevated blood pressure

Physician's haircut 0.28

Ibuprofen refill

Patient's church- related travel plan

Physician's home remodeling project

3.98

1.32

1.62

2.40

1.75

What does a visit look like


Findings – Median LengthsTotal AMC MCG ICS

VisitPt talk 5.3 8.0 4.0** 1.8**MD talk 5.3 5.9 4.7** 2.6**Length 15.7 23.3 13.4** 9.7**Major topicPt talk 2.0 3.0 1.7** 0.9**MD talk 2.3 2.4 2.3 1.7Length 5.3 6.7 4.8** 3.2**


Median Lengths of Time


Duration AnalysisAnalyze the likelihood that the topic or visit

would end, given how much time had already been spent on it.

To test duration dependence, we use the Weibull proportional hazard function (Cleves 2004).

At the topic level:h(t|xi)=h0(t) exp(β'xi)

(1)


Duration Analysis ResultsMajor Topics

Pt Talk MD Talk Topic Length

Mental Health .37** (85%) .52** (37%)

Psychosocial .48** (57%) 1.76** (-28%)

Pt initiation 2.53** (-22%)

MCG 1.58** (-26%) 1.60** (-20%)

ICS 2.93** (-54%) 1.98** (-28%)

Female Pt .73** (20%)


Summary Six topics per visit, all competed for visit timeTime spent by patient and physician on a

topic responded to many factorsLength of the visit overall responded little to

the nature of topics in visits and to patient’s health status

Organizational/financial factors were dominant determinants of visit length


Popular Press


Tai-Seale, McGuire, Colenda, Rosen, CookJournal of American Geriatric Society 2007

23

IntroductionLate-life mental disorders are common

(Charney et al. 2003)Elder suicide crisis (Kaplan 2001)PCPs deliver most mental health

treatment, esp. for elderly patients (Wang et al. 2006)

Practice guidelines call for a set number of office visits in which MH is discussed (Young et al 2001: 4v/5m)

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Study QuestionsWhat happens in a visit in which mental health problems are discussed?How much time is spent on addressing mental health issues?

How is that time spent?

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MethodsMixed Method ApproachQuantitative

How much timeQualitative

How is the time spentCritical discourse analysisConstant comparison

26

0.0

5.1

.15

.2D

ens

ity

0 5 10 15 20t2

Median =1.9 min.Mean =3.9 min.

What Mattered?One Parameter Logit/Duration

Probability Topic Length

Patient’s Mental HealthSF36 MH <42 (50% of patients) 25 2.3SF36 MH ≥42 (control) 19 1.6

Practice SettingAMC (control) 28 2.6Managed Care Group Practice 20 2.0Inner-City FFS Solo Practices 9 1.6**


What Mattered?One Parameter Logit/Duration

Probability Topic Length

White (control) .23 2.2

Non-White .16 1.7**

Female patient .27** 2.3

Male (patient) .12 1.2

Female Pt Male MD (control) .24 4.5

Female Pt female MD .32* 1.7

Male pt male MD .13** 1.2

Male pt female MD .07 2.5


How Was the Time UsedTheme 1: biopsychosocial

Patient indicated emotional distress MD took the time to investigate the disease,

the person, and the lived lifeMD Recognized mental disorderInadequate treatment

Theme 2: narrowly biomedical Patient indicated emotional distressPhysician did not follow up



D: (inaudible). What you been up to?P: I have just been crying my eyes out.D: Why?P: I don’t know. I can’t help it.D: Why?P: And then people ask me how I am, I just

cry.D: Oh, (pause.) Well I am not going to ask

you that anymore. (pause 2 seconds.) Why? Do you think you are puny?

P: No.D: No. Do they care, the people that ask?P: Yep.

Select ResponsesTwo U.S. Senate HearingsWA State Attorney General Media/Press coverage

News/Prof Org Press Date Circulation

New York Times Feb 07 40,000,000

New York Times Jan 08 40,000,000

American Medical News (AMA, front page)

Mar 07 251,000

Psychiatric News (APA) Nov 06 70,000

Good Housekeeping July 07 4,500,000

Lady’s Home Journal Dec 07 4,100,000

Prevention Magazine Jun 07 100,000AcademyHealth 2008 32

January 8, 2008Vital Signs

Aging: Mental Health Overlooked in Care of Elderly Patients

By ERIC NAGOURNEY

Depression and other mental illnesses are common among the elderly, and when they get treatment, it usually comes from their primary care doctors. But a new study suggests that those doctors may devote too little time to talking about those ailments.

When researchers reviewed videotapes of 385 appointments with elderly patients in three separate areas, they found the median time spent discussing mental health was just two minutes.

The study, which appeared in the December issue of The Journal of the American Geriatrics Society, was led by Ming Tai-Seale of the School of Rural Public Health at Texas A&M.

More than half the patients whose survey responses suggested they were depressed never spoke with their doctors at all about their emotional state. The subject came up in about a fifth of the visits over all.

But even when patients let their doctors know about their problems, the study found, the responses were often ineffective or worse.


Fruits for ThoughtsThe busy car mechanicCome back in one week, two weeks, etc.You and your insurance, (employer, CMS,

etc.) pay each time you go, no matter how much good was done in each visitWonderfulAwful


time allocation in primary care office visits

Documents

academyhealth 2008chart115

topics visits academyhealth

visitsduration patient

current patient

short visitsquality

foundation of medical

richard frankel

motivationmedical office